Maine’s new Medicaid rules

State tries to reduce narcotic prescription use

In this April 1, 2014 photo, Ernie Merritt stands with his back brace at his home in of Saco, Maine. Merritt, who runs a support group for chronic pain patients, supports Medicaid guidelines that promote alternative treatments, including physical therapy, in place of narcotic painkillers. Maine is leading in efforts to stem the flow of powerful opioid painkillers with unique Medicaid guidelines. (AP Photo/Blake Davis)

PORTLAND, Maine — Maine’s severe restrictions on opioid painkillers for Medicaid patients, requiring many to instead seek alternative pain management treatment for the past year, have sharply reduced the number of people obtaining highly addictive medications blamed for drug abuse and deaths around the nation.

Officials of MaineCare, the state’s version of Medicaid covering the poor and disabled, credit the new rules for a 17 percent drop last year in how many patients take opioid painkillers such as OxyContin and Vicodin in 2013, compared to 2012. Through fewer prescriptions and smaller doses, the number of pills dispensed was cut 27 percent, or 6 million pills for 15,000 fewer patients.

MaineCare may also have influenced doctors to write fewer painkiller prescriptions covered by private insurers, which decreased by 10,000 patients and 3.3 million fewer pills.

With the state experiencing “an epidemic in regards to opioid prescriptions,” the tighter guidelines are necessary to fight addiction trends, said Roy McKinney, director Maine’s Drug Enforcement Agency.

McKinney said an unintended consequence of the Medicaid rules — along with other state and national efforts — is that they dry up the source of illegally sold narcotics and may be contributing to a rise in heroin use as addicts seek the similar but cheaper alternative.

“There is a lot going on, but I think this data tells a very positive story because it’s not just cutting off access to a treatment,” said Kevin Flanigan, director of MaineCare services. Unlike past state efforts to cut painkiller use, the new guidelines require patients with lasting pain to use smaller doses and to try physical therapy, chiropractic work or pain acceptance therapy.

Maine’s new rules limit patients to painkillers for just two weeks a year, allowing renewal in two-week intervals with special permission. Patients with chronic pain lasting beyond eight weeks fall into a different category and are required to try alternative treatments such as cognitive behavioral therapy and chiropractic for pain relief.

Cancer and AIDS patients and others with lasting pain from end-of-life conditions still receive coverage for narcotic painkiller prescriptions. Hospice patients and those in nursing homes are also exempt.

In some cases, these guidelines have also been applied to non-Medicaid patients, resulting in fewer prescriptions for patients with private insurance, said Stephan Hull, director of the pain management center at Mercy Hospital in Portland.

“I think there are a number of physicians out there that are relieved to have those restrictions,” regardless of the insurance providers, he said.

But the data showed a troubling trend: some Maine physicians appear to be applying a different standard for patients whose pills are paid for by Medicare, workers’ compensation, and by the patients themselves. Those categories showed significant increases in the numbers of patients and pills prescribed.

Physicians can petition MaineCare on behalf of their patients, addressing concerns that those who need the medication for pain relief, including common back pain and neck pain, would be unable to get it.

“There are a number of situations where use of opioids is not only appropriate, it is the primary treatment,” said Flanigan. “Someone who is enrolled in hospice care and cancer has spread through their body and they have horrific pain. They need this medication in order to have a dignified life,” he said.

Former MaineCare patient Jeanie Devoe, 52, says her morphine prescription, along with 14 other medications, helps her manage full body pain and headaches stemming from three failed back surgeries.

The Westbrook resident was part of a pilot program at Mercy Hospital in Portland that is covered under the MaineCare guidelines. That program weans patients off medication by helping them cope with depression, anxiety and limited mobility that can accompany pain.

Devoe was able to cut her daily dose of morphine in half and quit using other opioid drugs.

Some patient advocates are critical that the new alternative treatments aren’t enough for some people.

Ernie Merritt, who runs a pain management support group in South Portland, says the six physical therapy sessions and the 12 chiropractic sessions covered by MaineCare “are definitely not enough.” He said he needed twice-weekly physical therapy for months for injuries he incurred as a pipefitter that led to multiple back surgeries.